Athene Nursing and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #1) was free from misappropriation of resident property when Housekeeping Supervisor (HS) and Certified Nursing Assistant (CNA) A used resident money for his/her personal use. The census was 155. The administrator was notified on 02/10/26 of the past noncompliance which occurred on 01/15/26. On 01/15/26, the administrator became aware of the staff to resident misappropriation of funds allegation involving Resident #1. Upon discovery, the facility immediately began an investigation, suspended the staff members, and in-serviced staff members on abuse, neglect, code of conduct, misappropriation, and exploitation. The deficiency was corrected on 01/17/26.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician-ordered prescription medications were received timely from the pharmacy and administered as ordered, affecting one resident who did not receive an antipsychotic medication for one month and had documented increased behaviors, including a resident-to-resident incident (Resident #173), and another resident who did not receive an antibiotic medication (Resident #133). The sample was 47. The census was 166. Review of the Medication Reordering policy, revised 8/1/25, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff observed a resident on the floor and failed to tell anyone, leaving the resident on the floor (Resident #183), and when staff left one resident without pants, leaving him/her exposed in the hallway (Resident #69). In addition, the facility failed to ensure the men and women's shower rooms on 3 Long Unit were in working order, preventing residents on that unit from using the shower room on their hall for an undetermined about of time, including one resident (Resident #147) who became aggressive due to his/her lack of access to showers. The sample was 47. The census was 166. Review of the facility's admission Agreement, dated, showed:-Right to a dignified existence: [...]

Inspectors wroteBased on observation and interview, the facility failed to post the Missouri Department of Health and Senior Services (DHSS) Elder Abuse and Neglect Hotline phone number and failed to provide contact information for the State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities by helping ensure their rights were preserved and respected) in a visible location. The sample was 47. The census was 166. Observation on 1/6/26 through 1/9/26, 1/12/26, and 1/13/26, showed: -No DHSS Abuse and Neglect hotline numbers or Ombudsman contact information on the facility's elevators;-The Corporate compliance contact information posted on the wall of Terrace 2. No DHSS Abuse and Neglect hotline number or Ombudsman contact information;-The Corporate compliance contact information posted on the double doors in the middle hall of Terrace 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received mail on Saturdays, a regular mail delivery day as identified by the United States Postal Service. The facility also failed to ensure mail was delivered timely. The sample was 47. The facility census was 166. During the resident council interview conducted with eight residents who represent the resident council, on 1/8/26 at 1:30 P.M., residents said mail is not delivered timely. It will sit in the activities room before they give it out. They have not had mail delivered this week. Some mail is time sensitive, that may have a due date or expiration date on it. One resident received his/her birthday card nearly one month late. He/She checked the postmark. He/She waited for the birthday card because there was $25 in there. He/She was upset it was delivered late. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directive/code status forms (a legal document, often a Do Not Resuscitate (DNR) order, that tells medical professionals not to perform cardiopulmonary resuscitation (CPR) if the heart and breathing stop) were documented, updated, and reviewed annually, in accordance with the expectations of the Director of Nursing (DON) and Administrator, for 7 sampled residents (Residents #1, #6, #12, #17, #39, #55, and #176). The sample was 47. The census was 166. Review of the Residents' Rights Regarding Treatment and Advance Directives policy, revised [DATE], showed:-Policy: To support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advanced directive;-Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was clean and homelike. The facility failed to ensure two of 47 sampled residents had a clean room and clean medical equipment (Residents #135 and #72), failed to ensure the 3rd floor terrace had a clean shower room and fire extinguisher cabinet, failed to ensure the 3rd floor windows were free from cracks, failed to ensure the floors in room [ROOM NUMBER] were clean and failed to ensure the loop main hallway was clean and free from odors. The sample is 47. The census was 166. Review of the facility's cleaning policy, undated, showed: -Policy: The facility has employed team members of environmental service at the facility to ensure that all areas of the facility, including resident rooms, offices, and public areas, are clean and homelike; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received appropriate activity of daily living (ADL, daily care) care to meet the needs of residents, including showers, personal hygiene, and nail care (Residents #15, #26, #143, #133, #153, #11, #21, #137, and #177). The sample was 47. The census was 166. Review of the facility's Activity of Daily Living policy, revised 4/23/25, showed:-Policy: The facility will, based on the comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-Care and services will be provided for the following ADLs:--Bathing, dressing, grooming and oral care;--Transfer and ambulation;--Toileting;-Explanation and compliance guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences for two residents (Resident #153 and Resident #166) who resided on The Loop. In addition, the facility failed to provide one-to-one activities for one resident (Resident #177) who was unable to participate in group activities. The sample was 47. The census was 166. Review of the facility's Activities policy, date last revised, 8/1/25, showed:-Policy: it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preference of each resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining dressing change orders for one resident that had a recent toe amputation (Resident #135) and by not changing one resident's leg wound dressing as scheduled and when it was saturated with fluid and dislodged (Resident #72). In addition, the facility failed to obtain a urinalysis (UA, a urine test to check for infection and obtain the results) as ordered for one resident (Resident # 3). The sample was 47. The census was 166. Review of the facility's Wound Treatment Management policy, revised, 9/1/25, showed:-Policy: To promote wound healing of various types of wounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 47 sampled residents received foot care and were on the podiatry list as needed (Residents #133, #72, #69 and #177). The census was 166. Review of the facility's activities of daily living (ADL) policy, dated 9/1/25, showed:-Policy: the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (tube that drains the urine from the bladder) had physician orders to include catheter care instructions, for two of three residents sampled with indwelling urinary catheters (Residents #182 and #10). The facility identified 12 residents with indwelling urinary catheters. The sample was 47. The census was 166. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 47. The facility census was 166. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow current infection control best practices and facility infection control policy for three of 47 sampled residents who were receiving antibiotic therapy. Concerns were noted with the indications for use in the antibiotic orders for all three residents (Residents #69, #166 and #26). The facility census was 166. Review of the facility's Antibiotic Stewardship Program Policy, revised 7/2/25, showed:-The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the Infection Preventionist (IP). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when facility staff left medication in one resident's room (Resident #135), who did not have a physician order for self-administration or medications to be left at the bedside. The sample was 47. The census was 166. Review of the facility's Resident Self Administration of Medications policy, last revised, 8/1/25, showed;-Policy: It is the policy of this facility to support each resident's right to self-administer medication; a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely;-Policy explanation and Compliance Guidelines: -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold notices were provided for two of four residents investigated for discharge (Residents #166 and #177). The sample was 47. The census was 166. Review of the facility's Bed Hold Notice Upon Transfer policy, dated 8/1/25, showed:-Policy: at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed;-The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1. Review of Resident #166's medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans included revisions to address individual care needs for two of 47 sampled residents, when the facility included incorrect information about diet orders and code status on resident care plans (Residents #12 and #143). The facility census was 166. Review of the facility's Care Planning - Resident Participation Policy, revised 8/1/25, showed:-The care planning process should include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care;-The facility will encourage and assist the resident and/or representative to participate in choosing care and treatment options including: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain weights as ordered for two residents (Residents #175 and #177). The facility also failed to ensure physician's orders for hemodialysis (a life sustaining treatment for kidney failure that removes waste and extra fluids from the blood) assessments were obtained for one resident out of three residents sampled for hemodialysis (Resident #5). The sample was 47. The census was 166. Review of the facility's Weight Monitoring policy, revised 9/1/25, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff attempted to communicate with a resident, who was non-English dominate speaking resident, in in a form and manner that the resident can understand. The facility did not provide an activity calendar in his/her dominate language, a communication board, or use a translation application to communicate with the resident (Resident #176). The sample was 47. The census was 166. Review of the facility's Culturally Competent Care policy, revised 4/23/25, showed:-Policy: to provide culturally competent care in accordance with professional standards of practice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety and adequate monitoring were provided during meals for two residents who had recommendations from Speech Therapy regarding proper positioning, type of required assistance during meals and/or monitoring during meals (Resident #109 and #11). The resident sample was 47. The census was 166. Review of the facility's Activities of Daily Living (ADLs) policy, revised 4/23/25, showed:-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.-Care and services will be provided for the following activities of daily living: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident that had a gastrostomy tube (g-tube, a tube that is surgically inserted into the abdomen to administer fluids, liquid nutrition, and medications) received the correct water flush during medication administration (Resident # 178). The sample was 47. The census was 166. Review of the facility's policy for Medication Administration via Enteral tube (feeding tube), date last revised 5/1/25, showed:-Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines;-Procedure: Verify physician orders for medication and enteral tube flush amount; Flush enteral tube with at least 15 milters (ml) of water prior to administering medications unless otherwise ordered by prescriber; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident's' behavior (Resident #177). The sample was 47. The census was 166. Review of the facility's Behavior Management policy, last revised, 8/1/25, showed:-Policy: Residents who exhibit behavioral concerns may require a behavioral management care plan to ensure they are receiving appropriate service sand interventions to meet their needs; The interdisciplinary team, including the family member, should develop a behavioral plan for each resident with identified behaviors; The plan should reflect the resident' personal preferences and usual routine, to the extent possible; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a narcotic medication was under a double lock and counted when a resident admitted and destroyed when the resident discharged from the facility (Resident #179). The sample was 47. The census was 166. Review of the facility's medication administration policy, dated 2/7/24, showed: -Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Resident #179's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/25, showed: -Diagnoses included chronic kidney disease, muscle weakness, and dementia; -Moderately impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that residents receive meals with appropriate nutritive content as prescribed by a physician to support the resident's treatment and plan of care, in accordance with his/her goals and preferences by failing to assure one resident received an appropriate substitute for starches (Resident #5). The sample was 47. The census was 166. Review of the facility's Assisted Nutrition and Hydration policy, revised 8/1/25, showed:-The facility will: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current CDC (Centers for Disease Control and Prevention) guidelines and the facility's infection control policies for two of 47 sampled residents. Staff failed to use an adequate disinfectant on reusable medical equipment during a resident's dressing change (Resident #9). Staff failed to use adequate Enhanced Barrier Precaution (EBP, precautions requiring the use of additional protective equipment by staff when providing care to reduce the spread of certain infections) interventions when providing direct care to a resident with a catheter (thin flexible tube) (Resident #135). The facility census was 166. Review of the facility's Enhanced Barrier Precautions policy, revised 4/23/25, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs by not providing baths/showers for two residents (Residents #13 and #12). In addition, the facility failed to ensure staff had enough towels and linen to assist residents timely with personal care as needed when staff and residents reported a towel and linen shortage. The resident sample was 16. The census was 166.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing) as recommended by the Centers for Disease and Prevention (CDC) and required by Centers for Medicare and Medicaid Services (CMS) for two out of two residents observed for wound care (Resident #2 and Resident #1) and when one resident's catheter drainage bag (a medical device that collects urine from a urinary catheter) lay on the floor (Resident #2). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to accurately document one resident's tube feedings (nutrition provided through a gastric tube (g-tube) a tube that is surgically inserted into the stomach) for one resident (Resident #8). In addition, staff failed to obtain and document a resident's blood pressure prior to the administration of Hydrochlorothiazide (used to treat high blood pressure) (Resident #14). The sample was 16. The census was 166. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when staff failed to transcribe new treatment orders timely and failed to accurately document treatments for three sampled residents (Resident #7, #3, and #8). Staff failed to obtain a physician order for a wound vacuum (wound vac, medical device that used suction to promote wound healing) for one resident (Resident #7). Staff failed to identify a deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), upon admission for one resident (Resident #3). The sample was 16. The census was 166. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident's nutritional status and effectiveness of interventions when staff failed to obtain admission weights and weekly weights as ordered for one resident with a diagnosis of severe protein calorie malnutrition upon admission (Resident #14). The sample was 16. The census was 166. Review of the facility's Weight Monitoring policy, dated 9/1/25, showed:-Based on the resident's comprehensive assessment, the facility will ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Weight can be a useful indicator of nutritional status. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary behavioral health care services for one resident (Resident #14). The resident was admitted with a diagnosis of vascular dementia (type of dementia caused by damage to the blood vessels in the brain) with behavioral disturbances. The facility failed to administer the resident's psychotropic medications as ordered and accurately document the administration of the medication or refusal. In addition, the facility failed to code the resident's behaviors accurately by documenting no behaviors even though there were reports of behaviors such as refusals, hitting, and attempting to walk without assistance. The sample was 16. The census is 166. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly assess a resident after a fall with a head injury. Staff failed to document neurological (neuro) checks after the head injury. The resident was sent to the hospital via 911 and diagnosed with a subdural hematoma (pool of blood between the brain and the outermost covering) twelve days after the fall (Resident #1). The sample size was three. The census was 152. The Administrator was notified on 7/31/25 of the past non-compliance. The facility had already started in-servicing staff on falls, interventions and documenting prior to the investigation. The facility was in compliance on 7/1/25. Review of the facility's Head Injury policy, dated 9/1/21, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of five sampled residents was free from physical abuse (Resident #1). Resident #1 had diagnoses including dementia, restlessness, agitation, cognitive communication deficit, and other abnormalities of gait and mobility. On 6/6/25 at approximately 5:00 P.M., certified medication technician (CMT) C told the resident he/she was nasty when the resident coughed or pretended to cough on CMT D's neck. CMT C began arguing with the resident, used profanity, and they threatened each other. CMT C pushed the resident and the resident pushed back. CMT C swung at the resident, hitting the resident around the face and neck, and the resident was pushed back against the wall. Staff intervened and pulled the resident away, causing him/her to fall to the ground. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate an altercation between Resident #1 and several staff members which resulted in the resident sustaining scratches on both sides of his/her neck and on his/her left hand. A registered nurse asked for written statements from the staff members involved and then read each others statements in front of each other. The next day, Certified Nurse Aide F reported to the Director of Nursing his/her statement was not correct and provided a new statement of events alleging CMT C had assaulted the resident. The DON did not investigate the incident further, including interviewing the resident and other staff members privately regarding the incident or advise the Administrator of the revised statement. This deficient practice affected one out of five sampled residents. The census was 158. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary medications as ordered by the physician for one of seven sampled residents (Resident #5). The facility failed to provide twice daily anti-seizure medication to the resident nine out of ten times over a five-day period. Facility staff also failed to notify nursing management and the physician of the medication errors. The facility census was 158. 1. Review of the Facility's Medication Administration Policy, revised 9/1/22, showed: -Medication carts should be stocked with adequate supplies of medications; -If expired medications are noted and cannot be administered, the nurse manager should be notified; -Any adverse side effects or refusals of medications should be documented and reported; -Discrepancies with orders or supplies of medication should be corrected and reported to the nurse manager. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors. The facility failed to ensure one resident's medication dose for Depakote (divalproex sodium, medication used to treat seizures and mood disorders) was entered correctly from the hospital after admission to the facility (Resident #3). This failure resulted in the resident receiving a lower dose of the medication for six days. The facility also failed to follow manufacturer and pharmacy recommendations and crushed a medication prior to administration for two residents (Resident #5 and Resident #1). One of the residents was hospitalized and found to have a low therapeutic level of the medication (Resident #1). The sample was 6. The census was 158. Review of the facility's Medication Administration policy, revised 9/1/22, included: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect when one employee used profanity while using their personal cell phone and providing feeding assistance to one resident (Resident #1), and four residents reported issues with staff being on their phones while working (Residents #2, #3, #5 and #4). The census was 143. Review of the facility's Professionalism - Customer Service policy, dated 9/1/21, showed: -Policy: It is the policy of this facility to provide professional, courteous service to our customers. Every employee is accountable for conducting themselves in a professional manner at all times. This facility strives to create an environment where the resident always comes first; -The facility is the resident's home and will be regarded as such. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Three of six residents complained that hot foods were served cold (Residents #13, #15 and #16). This deficient practice had the potential to affect all residents who ate their meals in their room. The census was 143. During an interview on 1/9/25 at 10:27 A.M., Resident #13 said he/she eats in his/her room. The food is usually cold by the time he/she gets it. Staff will heat it up in the microwave if you ask. During an interview on 1/9/25 at 11:19 A.M., Resident #15 and Resident #16 both said the food is improving. As far as food being warm when it is served, sometimes it's warm enough and sometimes it's not. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety by failing to date opened packages of food. The facility also failed to ensure dining room furniture was clean and free of roaches and failed to keep kitchen equipment clean when staff failed to clean the wells of a steam table used to serve resident's food. The sample size was 25. The census was 143. Review of the facility's Food Safety Requirements, dated 9/1/21, showed: Policy: Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; Definitions: -Food service: the process involved in actively serving food to the resident; -Food service safety: refers to handling, preparing, and storing food in ways that prevent foodborne illness; -Policy Explanation and Compliance Guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prepared food items were served at a safe and appetizing temperature when the staff failed to maintain the internal temperatures of hot food items placed in hot holding at 135 degrees Fahrenheit (F) or higher to prevent the growth of food-borne pathogens and potential food-borne illness. This deficient practice had the potential to affect all residents who ate food from the facility's kitchen. The facility census was 138. Review of the facility's Food Temperatures Policy, dated 9/1/21, copyright 2021, showed: -Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled; Definitions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors, when staff failed to administer one resident's diabetes medications for several days (Resident #2). The sample was 5. The census was 131. The Administrator was notified on 8/2/24, of the past non-compliance which began on 7/21/24. The facility began an investigation, audited resident medications, reviewed all new admissions orders, interviewed staff and residents, had a meeting with the pharmacy, and in-serviced staff on following physician orders, the protocols when a medication is not available, and verifying medications for new admissions. The deficiency was corrected on 7/31/24. Review of the facility's Medical Provider Order Policy, revised 4/7/22, showed: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of six sampled residents were free from physical abuse. The residents' right to be free from physical abuse were violated when during two separate incidents a resident (Resident #2) hit four residents (Resident #5, Resident #6, Resident #3 and #4) in the face and stomach. The census was 92. On 7/1/24 at 5:00 P.M., the Administrator was notified of the past noncompliance, which occurred on 6/28/24. On 6/28/24, the Administrator was notified by staff of the incident and an investigation was started. The facility immediately took steps to protect the residents and set interventions in place to prevent further abuse. The alleged violation was reported within the required timeframe. Facility staff received education on the facility's Abuse and Neglect Policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pre-admission screenings were completed timely and failed to incorporate the recommendations from the Pre-admission screening and resident review (PASARR) Level II determination and the PASARR evaluation report for one of six sampled resident's (Resident #1's) plan of care. The census was 92. Review of the facility's Resident Assessment-Coordination with PASARR Program policy, revised on 9/1/21, showed: -This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression, for one sampled resident (Resident #1) out of six sampled residents. The facility failed to inform staff how to handle the resident's escalating behaviors. The facility census was 92 residents. Review of the facility's Comprehensive Care Plan policy revised on 9/1/21, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #2 was free from financial misappropriation resulting in the resident's credit card being taken by two staff members. The census was 134. The Administrator was notified on 6/4/24 of the past non-compliance, which began on 5/31/24. The facility immediately began an investigation of the incident and removed the staff members who misappropriated the resident's funds pending an investigation. The administrator began in-servicing staff on abuse, neglect, and misappropriation. The noncompliance was corrected on 6/3/24. Review of the facility's abuse, neglect and exploitation policy, dated 8/22/22, showed: -Policy: [...]

Inspectors wroteBased on observation, interview, and the facility policy review, the facility failed to ensure food was labeled and dated properly according to professional standards for food prepared from the facility's kitchen. This failure had the potential to affect 126 of 127 residents consuming food from the kitchen.

Inspectors wroteBased on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures which addressed resident care and safety, quality of life, and resident choice. This failure had the potential to affect all 127 residents who currently lived in the facility. (Cross Reference F868)

Inspectors wroteBased on document review, interview, and review of facility policy, the facility failed to ensure that the quality assessment and assurance (QAA) committee met at least quarterly. This had the potential to affect the care and services for each of the 127 residents in the facility.

Inspectors wroteBased on observations, interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility for 127 of 127 census residents. In addition, the facility failed to ensure the Certified Nursing Assistant (CNA) 5 performed hand hygiene after doffing (removing) gloves and failed to ensure a serving of applesauce was replaced, after being contaminated, for one of one resident (Resident (R) 83) of 29 sampled residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement their system to monitor the use of antibiotics for 127 of 127 census residents. Specifically, the facility failed to monitor and evaluate antibiotic use and track measures of antibiotic usage in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure grievances shared at the monthly meetings by seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) were resolved or a rational provided.

Inspectors wroteBased on interview, resident council minutes review, and facility policy review, the facility failed to review resident rights with seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) of 29 sampled residents.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure activities were provided to the residents who resided in the secured unit when the Activity Assistant was not assigned to work. In addition, the facility failed to provide individual activities to three out of seven residents (Resident (R) 130, R23 and R25) of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that electrical equipment with exposed cord was not used in a dementia secured unit with the potential to cause accident hazards, such as tripping and/or falling of 26 residents who ambulated and wandered within the unit.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored in a locked storage area when left unattended for one of five medication rooms in the facility.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure three residents (Resident (R) 109, R24, and R39), out of 31 residents on the secured unit, were provided a timely scheduled lunch meal. As a result, three residents complained of being hungry and were not aware of an unplanned change in the schedule for meal delivery.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, including but not limited to ensuring housekeeping and maintenance services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. This had the potential to affect 127 of 127 residents who resided at the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to respect two of 29 sampled residents' (Resident (R) 23 and R104) right to be treated with respect and dignity. R23 was brought to the common area and dining area of his unit without trousers on, and R104's urinary catheter drainage bag was left uncovered.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the physician was notified of a significant weight loss for one of four residents (Resident (R) 98) reviewed for nutrition of 29 sampled residents. (Cross Reference F641, F657, R692, F726, and F777)

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess a Broda chair (a positioning wheelchair) as a restraint and failed to obtain a physician's order, provide a medical symptom, and obtain consent for the use of a restraint for one of one resident (Resident (R) 23) reviewed for restraints of 29 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 23) reviewed for chemical restraints did not receive a chemical restraint as a convenience to treat behaviors. R23 was prescribed Haldol and Seroquel, both antipsychotic medications, for behaviors and without a medical symptom for their use.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 94) and/or responsible party (RP) were given a written bed hold policy at the time the resident was transferred/discharged to the hospital of 29 sampled residents.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R) 98, R94, and R23) out of 29 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the resident.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete Pre-admission Screening and Resident Reviews (PASARR) as required for two of four sampled residents (Resident (R) 118 and R6) reviewed for PASARRs. R118 was admitted on [DATE] with a 30-day PASARR exception but was still a resident on 02/12/24. The facility did not perform a Level I PASARR screening after 30 days or refer for a Level II PASARR, if necessary, within 40 days of the resident's admission.

Inspectors wroteBased on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for three of 29 sampled residents (Resident (R) 130, R68, and R77) reviewed for care plans.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure one of five residents (Resident) (R) 98) and/or their representative was invited to participate in the resident's quarterly care plan meeting and the facility failed to update the activity care plan for one of seven residents (R23) reviewed for activities of 29 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinent care; assistance with eating, drinking, and dressing; complete transfers in a safe manner; and/or provide showers as scheduled for two of four residents (Resident (R) 23 and R186) reviewed for activities of daily living (ADLs) of 29 sampled residents. R23 and R186 were dependent on staff for meeting their ADL needs. R23 was not provided incontinent care or offered and/or encouraged to have fluids during a three-hour observation, was not assisted with dining during one observation, and was not transferred in a safe manner. R186 was not assisted with showers twice weekly as care planned.

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician orders were followed for two of 29 sampled residents (Resident (R)186, and R88). This failed deficiency had the potential to allow residents to go without needs being met or care being provided when physician's orders were not in place.

Inspectors wroteBased on observation, record review, staff interviews, and facility policy review, the facility failed to create a care plan, with specific approaches, which addressed one of four residents (Resident (R) 98)'s diagnosis of malnutrition upon admission. The facility failed to ensure a dietary intervention was properly implemented as directed by the resident's care plan that addressed potential weight loss. The facility failed to ensure the physician provided a clinical rationale for the resident's significant weight loss. This had the potential to increase the resident's opportunity for unintended weight loss.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen concentrator was cleaned, had a filter on the inlet where the air came into the machine, and ensured an E cylinder was secured for one of one resident (Resident (R) 77) of 29 sampled residents. This deficient practice had the potential to allow for an increased chance of infection and the improper storage of the cylinder causing severe injury.

Inspectors wroteBased on record review, document review, interviews, and review of the facility assessment, the facility failed to ensure one Licensed Practical Nurse (LPN) 3 was competently trained to read the results of a radiology report for one of one resident (Resident (R) 98) of 29 sampled residents. (Cross Reference F777).

Inspectors wroteBased on interview and record review, the facility failed to ensure medication irregularities were identified and reported by the Consultant Pharmacist for one of six residents (Resident (R) 23) reviewed for medication regimens of 29 sampled residents. R23 was prescribed Haldol and Seroquel, both antipsychotic medications with Black Box Warnings, without adequate indication for use. (Cross Reference F605)

Inspectors wroteBased on record review, hospital record review, manufacturer guideline review, interview, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 130) reviewed for unnecessary medications of 29 sampled residents had appropriate indications for use for an antipsychotic (Thorazine), failed to have proper black box warnings, and failed to ensure behaviors and side effects were monitored associated with this medication.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure the radiology report was read correctly for one of one resident (Resident (R) 98), by one Licensed Practical Nurse (LPN) 3 and as a result there was a delay in care after the resident sustained an acute fracture of the proximal humerus.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide influenza vaccines for two of five residents (Resident (R) 23 and R118) reviewed for immunizations of 29 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision to ensure the safety of one of three sampled residents (Resident #1) diagnosed with vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) and encephalopathy (alteration in consciousness caused by diffuse/global brain dysfunction due to a chemical imbalance). On the morning of 1/9/24, the resident became agitated and physically aggressive towards staff. He/She forced his/her way off the locked unit on which he/she resided, was redirected back onto the unit by staff and then shattered a first-floor window in the secured unit and climbed through it. He/She was assessed and treated at the hospital. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for five residents (Resident #14, #15, #16, #17 and #18). Additionally, the facility failed to allow residents access to petty cash on an ongoing basis. The facility census was 133. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 11/09/23, showed the following residents with personal funds held in the facility operating account. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 80 residents. The facility census was 133. 1. Record review of the facility maintained bank statements for the months 01/2023 through 08/2023 showed no documentation showing any reconciliations. Record review of the facility maintained 09/2023 reconciliation forms, dated 10/05/23, showed the attempted reconciliation had a difference of negative $1,136.62. Record review of the facility maintained 10/2023 reconciliation forms, dated 11/02/23, showed the attempted reconciliation had a difference of negative $403.56. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 133. 1. Record review of the facility maintained Resident Trust Bank Statements and Resident Trust Balance Reports for the period 01/2023 through 10/2023, showed an average monthly balance of $214,759.12. Record review of the facility maintained Accounts Receivable A/R Aging Report, dated 11/09/23, showed the facility held an average balance of resident funds in the amount of $7,536.70 in the facility operating account. Record review on 11/09/23, of the Department of Health and Senior Services approved bond list showed the facility did not have an approved bond, making the bond insufficient by $324,000. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #13) was free from misappropriation of resident property when the former Social Services Assistant (SSA) A used resident funds for his/her personal use. The facility census was 133. 1. Record review of the facility maintained Resident Trust Statement for the period 05/05/23 through 11/09/23, showed the following withdrawal from Resident #13's account: Date Amount Description 08/22/23 $3,300.00 Personal Needs Items Record review of the facility maintained Resident Face Sheet shows Resident #13 is his/her own responsible party. Record review of the facility maintained paperwork for Resident #13's Resident Trust Statement, showed written authorization for the $3,300.00 withdrawal was not obtained until 10/20/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide acceptable nursing practice for one resident with bilateral (right and left) leg wounds (Resident #1). The resident routinely refused care and treatment from nursing staff, and he/she had physician orders for treatments to be performed daily by the resident with staff monitoring the treatments. Staff documented the treatments were completed, however during interviews, staff said they falsely documented completion and had not observed the resident perform his/her wound treatments as ordered. On 9/19/23, the resident called Emergency Medical Services (EMS) for assistance after a fall. EMS arrived, noted an overwhelming odor and had concerns of severe infection and necrosis (dead tissue) in the open wounds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify Resident #4 of all rules and regulations governing resident conduct and responsibilities during his/her stay at the facility. The facility failed to disclose information to the resident regarding a prohibition of cannabis products in the facility and failed to establish a written policy for residents to review and understand prior to or upon admission, as appropriate during the resident's stay, and when the facility's rules change. The census was 131. 1. Review of the Resident #4's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE]; -Cognitively intact; -No behaviors noted; -Diagnoses included depression, osteoarthritis (inflammation of the bone) of hips, and pain in unspecified joint; -Received antidepressants and opioids every day for seven days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for 13 of 14 residents investigated for activities (Residents #68, #84, #7, #94, #38, #40, #8, #31, #41, #90, #15, #11, and #86). The facility failed to have activity staff in sufficient numbers to provide a complete activities program, and failed to ensure the facility assessment addressed activity staff under their staffing plan and/or staff training/education. The facility failed to provide one on one activities to residents, failed to ensure evening activities occurred or have activity staff available to assist residents in attending weekend activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals to residents in a timely manner and meet the needs and preferences of the residents wanting to eat in the dining room. This deficient practice had the potential to affect all residents who ate at the facility. The census was 96. Review of the resident council meeting minutes, dated 6/30/21, showed the following for dietary: -One resident said: it sucks; -One resident said: They're not cooking it, they're short staffed down there; -One resident said: No cooks down there in the evening; -Two residents said: Meals get to rooms considerably later, sometimes lunch is at 2:00, any day, weekends are worse; -One resident said: the dream of eating in the dining room; -Response: We are short staffed, so when we fix our concerns, then we can get back to the dining room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Seven of seven residents attending the resident council meeting complained about the food, the lack of choices, and the food temperatures. In addition, two residents complained about the food during individual interviews (Resident's #47 and #99). Furthermore, the facility failed to follow standardized recipes for preparing pureed foods. These deficient practices had the potential to affect all residents who ate at the facility. The census was 96. 1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary: -Food is icky, I stopped eating it; -No documentation which resident in attendance voiced this concern; -He/she got sick the same day I did. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide resident council members with verbal and written responses, actions and rationale taken regarding their concerns. In addition, the facility failed to provide a timely written response to a grievance regarding missing personal items for one of 20 sampled residents (Resident #11), in accordance with the facility's grievance policy. The census was 96. Review of the facility's Grievance/Complaints, Filing, revised April 2017, showed the following: -Policy Statement: Resident and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state Ombudsman). -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The sample size was 20. The census was 96. Review of the resident trust account for the past 8 months, from December 2020 through July 2021, showed an average monthly balance of $118,000.00. This would yield a required bond in the amount of $177,000.00 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), dated 2/26/21, showed an approved bond of $175,000.00. During an interview on 8/23/21 at 8:00 A.M., the administrator said it was possibly due to the residents receiving their stimulus checks, which is why the current surety bond is short.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was followed, in the event the resident was found without signs of life, when the facility failed to maintain accurate, congruent, and easily accessible documentation of advance directives for five residents investigated for accuracy of code status (Residents #15, #11, #71, #100, and #32). The sample was 20. The census was 96. 1. Review of the facility's census and room roster, showed Residents #15 and #11 identified as residing in the locked memory care unit. Observation of the code status book, located at the nurse's station on the locked unit, reviewed on 8/30/21 at 7:45 A.M., showed (Residents #15 and #11) did not have hard copies of advance directive information in it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sufficient amount of supplies to meet the care needs of residents in a dignified manner. This deficient practice had the potential to affect all residents receiving bathing services in the facility. The census was 96. Review of the Resident's Handbook, revised in 2018, provided upon admission, showed: -admission Agreement; -Our responsibilities: We will provide you with room and board, nursing services, personal and housekeeping services, and routine supplies required by your condition; -Appendix 5, Items and Services Included in the Daily Rate: -Private pay: Items and services included in the daily rate, include nursing services, bathing services, and linen, housekeeping and maintenance services; -Medicare Part A: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when four out of four controlled substance shift change count sheets, for August 2021, were observed to lack consistent documentation of the count of controlled substances at shift change. The census was 96. Review of the facility's Controlled Substances policy, revised 12/2012, showed: -Policy statement included: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper storage of medications in three of three treatment carts, and three of four medication carts observed. The treatment carts had medications not labeled properly. The medication carts contained spills over supplement containers, opened food, and improperly labeled medications. The facility had five medication carts and three treatment carts. The census was 96. Review of the facility's Storage of Medications policy, revised 4/2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs shall be stored in the packaging, containers, or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide for requests of additional food at meal times and failed to offer nourishing snacks at bedtime. This had the potential to affect all residents. The census was 96. 1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary: -Food is icky, I stopped eating it; -No documentation which resident in attendance voiced this concern; -He/she got sick the same day I did. Saturday and Sunday. I know it was off the food; -No documentation which resident in attendance voiced this concern; -Food is always cold; -Lots of unintended weight loss; -The kitchen has not been serving fresh fruit. There used to be fruit available anytime. Maybe COVID is an issue. Would bananas and oranges be safer due to their skins?; -We want to use the dining room again. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to dietary and activity concerns. This had the potential to affect all residents in the facility. The census was 96. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program policy, dated 2001 and revised on 2/2020, showed: Policy Statement: -This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; Policy Interpretation and Implementation: The objective of the QAPI program are to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff received the required tuberculosis (TB) screening as required per their policy, perform proper hand hygiene when providing personal care for two residents (Residents #16 and #84), ensure a shared electric razor was disinfected between uses (Resident #9), and ensure staff appropriately wore masks to cover both their nose and mouth when around residents or other staff. The census was 96. 1. Review of the facility's Tuberculosis Infection Control Program Policy, revised January 2012, showed: -Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #16, #13, #49, #47, #19 and #39) with side rails to reduce the risks of accidents. The facility identified 22 residents with side rails in use. Residents #16 and #13 were not identified by the facility as having side rails. The sample was 20. The census was 96. Review of the FDA (Federal Drug Administration) documents, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed bed rails, also called side rails, may be used as a restraint, reminder, or assistive device. Evaluating the gaps in hospital beds is one component of a mitigation strategy to reduce entrapment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #47 and #93). The sample was 20. The census was 96. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for three residents (Residents #304, #7, and #73). The sample was 20. The census was 96. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Role of the Administrator: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation for two residents discharged from the facility (Residents #550 and #303). The census was 96. 1. Review of Resident #550's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/20, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required for ambulation, transfers, bed mobility and personal hygiene; -Impairment to bilateral legs; -Received physical therapy (PT) four days a week and occupational therapy (OT) five days a week. -Diagnoses included progressive neurological conditions, high blood pressure and diabetes. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for one of 20 sampled residents (Resident #310). The resident's care plan did not address his/her wounds, pressure ulcers, potential for pain, refusal of care and did not specify the amount of staff assistance needed with his/her activities of daily living (ADLs). The census was 96. Review of Resident #310's progress notes, dated 9/1/20 at 11:17 P.M., showed he/she was admitted around 6:30 P.M. The resident's admitting diagnoses were respiratory failure and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received showers as scheduled/desired. Twenty residents were sampled and problems were identified with three (Residents #19, #94 and #99). In addition, one resident selected as an expanded sample complained of not receiving showers (Resident #39). The census was 96. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/21, showed: -Adequate hearing and vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands - clear comprehension; -Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 15 of 15, which indicates intact cognition; -Rejection of care: Behavior not exhibited; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to monitor the effectiveness of medication, and to notify the physician to address the abnormal medication level, for a one resident (Resident #84). The resident had a seizure disorder and required the use of anti-seizure medications. The facility failed to ensure the medication was administered in sufficient amount to ensure a therapeutic level. This resulted in the lab test, used to determine if the medication was at a therapeutic level, showing the levels as below therapeutic range. The facility failed to notify the physician that the levels were below therapeutic range. This resulted in the resident having seizure activity resulting an abrasion to the head. The facility census was 96. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and to ensure each resident received adequate supervision and assistance devices to prevent accidents for 19 residents who resided on the secured unit when the facility failed to ensure water temperatures were maintained at a safe level below 120 degrees (°) Fahrenheit (F). In addition, staff failed to implement a care planned intervention to encourage the resident to use a walker for ambulation, and left one resident on the toilet unattended who required supervision (Resident's #41, and #94). The census was 96. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff positioned two residents' urinary catheter drainage bags off the floor. The facility identified seven residents with indwelling urinary catheters (a tube inserted into the bladder to drain the bladder of urine. Urine is collected in a drainage bag until emptying). Of those seven, five were sampled and problems were identified with two. (Residents #99 and #57). The census was 96. Review of the facility Catheter Care, Urinary policy, dated 2001 and revised on 2014, showed: Purpose: -The purpose of this procedure is to prevent catheter-associated urinary tract infection;; Infection Control: -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for two of five residents investigated for nutrition (Resident #68 and #86). This resulted in both residents experiencing a significant weight loss. The sample was 20. The census was 96. 1. Review of Resident #68's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/21, showed: -Severely impaired cognition; -Extensive assistance with eating; -Diagnoses included progressive neurological conditions including aphasia (difficulty forming and expressing spoken words) and Multiple Sclerosis (a progressive decline in neuromuscular function); -Recorded weight of 131 pounds (lbs); -Care Area Assessment Summary (CAAS): Cognitive loss/dementia and nutritional status triggered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents using bed/side rails, had adequate assessments to determine the side rails were appropriate and safe to be used and/or had physician's orders. The facility identified 22 residents with side rails in use. Two of 20 sampled residents (Residents #16 and #63) and one expanded resident (Resident #13) had side rails but were not identified by the facility as having them. The census was 96. Review of the facility's Proper Use of Side Rails policy, revised December 2016, showed: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on residents that are complete and readily accessible in accordance with accepted professional standards and practices for two of 20 sampled residents (Residents #251 and #250). The census was 96. 1. Review of Resident #251's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/20, showed: -admission date: 10/26/20; -Severe cognitive impairment; -No moods or behaviors; -Total dependence with activities of daily living; -Diagnoses of medically complex conditions, high blood pressure, diabetes, Alzheimer's disease, Parkinson's disease and asthma; -Feeding tube; -Tracheostomy Care (an opening in the front of the neck so a tube may be inserted so the person can breathe). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain reports with respect to infection control surveys and complaint investigations made during the preceding three years, for review by residents, family members and legal representatives of residents. The census was 96. Observation on all days of the survey, from 8/19/21 through 8/31/21, showed a survey binder displayed across from the receptionist's desk near the front entrance to the facility. Review of the survey binder, showed the binder contained annual survey results from April 2019, but did not contain the results of any infection control surveys or complaint investigations completed October through December 2019, 2020, or January through June 2021. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure temperatures were taken for the walk-in refrigerator and the walk-in freezer of the main kitchen. This deficient practice had the potential to affect all residents who ate at the facility. The census was 96. Observation on 8/19/21 at 8:36 A.M., of the kitchen, showed no temperature logs for the walk-in refrigerator and freezer. During an interview on 8/24/21 at 6:07 A.M., Dietary Aide (DA) M said prior to 8/19/21, they were taking the temperatures of the walk-in freezer and refrigerator, but were not documenting the temperatures. They were short-staffed, but began recording the temperatures after 8/19/21. During an interview on 8/31/21 at 9:04 A.M., the administrator said the kitchen was short-staffed. Temperature logs should be recorded and maintained in the kitchen.